MILEPOST 66 FIRE ROPES INCIDENT FACILITATED LEARNING ANALYSIS

Transcription

1 MILEPOST 66 FIRE ROPES INCIDENT FACILITATED LEARNING ANALYSIS

2 INCIDENT SUMMARY On September 29, 2012 the Milepost 66 Fire was in its fourth operational period under a Type III Organization. Most of the containment objectives for the fire had been met with the exception of a portion of line located on the east edge above old Highway 30 (HWY), a pioneer road now used for non-motorized recreational use. There was still the potential for the fire to escape east due to continuous fuels along this steep terrain. The steepness of the slope also limited visibility into an area, known as the bench, which was producing small amounts of smoke. Helicopters had worked this area for a few days but were unable to complete the suppression objective along the still smoldering hot edge. The Type III IC had concerns that more bucket drops would only increase the exposure to the pilots and continue to fail to meet suppression objectives on the eastern edge of the fire. Many efforts had also been made to reach the bench by handcrews during the previous four operational periods but the steepness of the slope made accessibility to the hot areas on the eastern edge too dangerous. The Type III IC was aware that some Columbia River Gorge National Scenic Area (CRGNSA) personnel were certified in tree climbing and low angle rope use. The Type III IC, the Division Supervisor, and the local CRGNSA Fire Duty Officer (FDO) met to discuss the situation and agreed that it was too dangerous to put anyone on the bench 70 above the highway without some form of protection or a fall arrest device. They further agreed that it might be an option to use the CRGNSA Engine Crew to perform a low angle rope operation to complete the mop-up and cold-trailing of this steep portion of the incident. BACKGROUND Working in steep terrain was identified as a safety issue for firefighters in the gorge dating back to 1997 when fire leadership became uncomfortable seeing firefighters using fire hose and vegetation as climbing aids to access steep unforgiving terrain. The FMO said, There s got to be a better way of doing business. He researched the FS manuals; Health and Safety Handbook for ropes use in the agency but couldn t find any supporting protocols and procedures. Knowing the issue wasn t going away he was reminded that his fire 2

3 crews are often first responders to incidents in steep terrain (example; Eagle Creek and Multnomah Falls) that require the local search and rescue teams (SAR) to extract injured hikers using low and high angle rescue techniques. The FMO thought if the SAR were trained in using ropes in the Gorge, perhaps they would be willing to train his fire crews. In 1998 the CRGNSA started to invest in ropes and knot training. They started out small because access to steep terrain to suppress wildfire wasn t always needed. In fact this technique was rarely used. The use of ropes only came into play on the occasions when all other methods to suppress the fire were exhausted. This was a very limited program. In 2004 the CRGNSA was starting to work more closely with the local SAR and the rope program became more formalized. One of the local SAR programs is the oldest mountain rescue program west of the Mississippi River. A Fire Chief who was a member of the local SAR program had vast knowledge of experience in high and low angle rope work. This included a season on the John Day Oregon Rappel Crew. He was later hired by the CRGNSA as an Engine Captain (He will be referred to as the Crew Leader #1 in the FLA). In 2011 the CRGNSA hired an Assistant Fire Management Officer with a tree climbing background. She is a certified tree climber and instructor for the USFS. Fire crews were given the opportunity to develop additional climbing skills under this formalized training. The rope program was continuing to evolve. Equipment Used 3

4 Incident Summary Continued The CRGNSA FDO, IC, and Division Supervisor discussed the potential for the fire to keep moving laterally along the slope to more adverse terrain and higher resource values and agreed that, This would be the place to make a stand. They evaluated the rope operation from the old HWY and agreed to move forward. The FDO then notified his Engine Captain that the next day s operation might include a low angle rope operation above the highway and asked him to visit the site and evaluate the potential operation. Information considered by the IC, FDO and Crew leader to make the decision to move forward with the operation: Zigzag IHC had made attempts to get the fire out, using ropes already Thick duff and moss allowed the fire to creep out of the control lines and continue to spread, even with continued water drops Access to the top of fire. A second crew sent folks into the bench area and made attempts to put the fire out. While they were okay working on the steepness of ground on the bench they were not comfortable with the potential consequences if someone lost their footing. They asked for the rope option originally. The reduced risk of having firefighters trained in rope techniques compared to having unprotected firefighters working on the slope. The FDO had a high degree of comfort with the Captain and Assistant Captain accepting the mission, the Captain being a high angle rope rescue instructor who had shown good judgment in the past, turning down requests for work if the exposure was too high. There were good anchor points available above the area they would be working on the bench, which was low angle work. There was no rain in the long term forecast with a red flag warning predicted with winds of 30+ mph. The use of sprinklers was considered but would also entail the use of ropes for set up and there was concern that they too would be ineffective due to fire smoldering under the thick bed of moss on the rocks. The option of letting the fire spread to a different location was also assessed; the area gets steeper for hundreds of yards to the east before mellowing out to something accessible. This option would have required four to five burning periods to establish a containment line if the fire didn t blow out due to wind events in the meantime. This option would have increased exposure to firefighters and as well as the risk of the fire growing substantially and would have left the door open for the fire to escape onto private timber land and towards homes. The longer potential exposure to firefighters coupled with the potential threat to the public solidified the FDO s decision to allow the Captain to assess the mission while the area of concern was a 40 x 40 smoldering fire. 4

5 According to the FDO, The decision to let them take on the rope work was not taken lightly, every time we have used ropes it is to make the job safer, but the need to use them has to be there. It is not often that ropes are used on fires here, some years not at all On September 30, at 0900 the CRGNSA Engine Crew arrived below the steep bench area of the eastern edge of the fire also known as the waterfall. The crew of three was briefed by the FDO on the day s mission. Two of the three crew members had completed USFS Tree Climbing Training in the spring and both have extensive climbing and rope experience. The third crew member didn t have any formalized training but was familiar enough with the ropes program to provide logistical support. They were all to hike to the top of the fire, packing the gear needed to complete the mission. Prior to the climb, the crew leader and the crew performed risk assessments of the operation from the highway looking up to the bench where the smoke was located. There was flagging on the top of the fire to give them a visual line of sight and relationship from the bottom to the top of the fire. They spent approximately an hour going over the mission, including reviewing the knots to be used, equipment checks, and the procedures and terminology used in rope operations. The crew leader again asked specific questions regarding the mission to ensure everyone was prepared before they started their hike to the top. The FDO instructed the third crew member to take photos of the operation when possible for program documentation. Some of the photos are used in this FLA. At approximately 10:00 the three CRGNSA crew members started to hike up the hose lay on the west draw (in the black) toward the top of the fire. Once at the top they would contour to the east and get above the bench. Crew member #2 was in his first year of official rope work on the unit but had been a recreational climber for years. Crew member #3 stayed at the top of the fire and when directed removed and back hauled gear to the HWY. 5

6 While the original piece of ground identified as requiring additional work was low angle, there were two options for accessing this piece of ground. The first was a traverse across similar ground and the second was the high angle rappel (cover photo). The crew executing mission opted to use the rappel option. Crew member #1 and #2 constructed anchors for the ropes at the top of the fire above the bench. Crew member #2 descended the rope toward the bench first so crew member #1 could observe (the rope was just east of the fires edge in the green). Once crew member #2 arrived at the bench, he anchored himself to the bench and began to work the fire. At this point crew member #1 adjusted his anchor, moved west and began his descent to the bench. Crew member #1 found heat during his descent from the top, took action, and continued his descent. Once both crew members were on the bench, crew member #3 released the anchor at the top of the fire. Both crew members on the bench commented it is steeper than we thought it would be. After hours (between 1.5 and 2.5 hours) of working safely, and choreographing the operation to ensure the two firefighters were not working above each other, they finished securing the line. They discussed options for getting down from the bench. A direct rappel was the option chosen by the firefighters. In their opinion it was the option with the least amount of exposure to injury the safest method to get down. View from top looking down. 6

7 They completed cold-trailing and mop-up on the bench and prepared for their second rappel; from the bench to the HWY. While anchored, in an effort to keep material from rolling off the bench during the descent down to the HWY, crew member #2 kicked loose rock and vegetation away from the descent area. At this point both crew members felt good about the mission, they were glad to get this piece of the fire cold trailed, as it no longer posed a threat to the east. Their attention turned to the descent back to the HWY. Crew Leader #1 wanted to make sure they had enough rope to get down from the bench to the HWY so they combined ropes, used the same anchor point, and started the descent to the HWY. Crew member #2 went first. At this point in the operation, the descent transitions from a low to a high angle rappel yet there was no acknowledgement of that transition between the two of them. As crew member #2 reached the edge, or lip, of the 70 cliff, he though it s a little loose, meaning that rock was falling from the slope below the bench. The loose rock was also noticed by someone watching from below. Crew member #2 continued his descent down the rope when his hand tool got stuck about 20 below the lip. He reached back to make an adjustment and continue his descent. At the halfway point crew member #2 called crew member #1, I just got hit by a rock. Crew member #3 was at the HWY taking photos and witnessed a rock fall and hit crew member #2. Crew member #3 didn t see where the rock came from but estimated the rock was the size of a small melon or softball. This happened approximately 30 above the HWY. Crew member #2 paused and then continued the descent to the HWY. Crew member #3 called out to #2, are you OK?, received no response and started moving toward #2. By the time crew member #3 arrived, #2 said he wasn t doing well. Crew member #2 was bleeding and had some deformity on the left side of his face. Crew member #3 removed #2 s harness and called for the trauma kit from the engine. Crew member #3 said it was obvious that Crew member #2 was in serious pain. Medical Response When crew member #2 reached the HWY, a paramedic from one of the engine crews, who had been prepositioned on site, had witnessed the event and immediately started a patient assessment. A call was made from the ground crew to member #1, also a paramedic, to get down here because crew member #2 is hurt. Crew member #1 got down to the HWY (2-3 minutes) and also assessed crew member #2. Some deformity around the right side of the face along with a deep puncture wound close to the temple area confirmed the need to transport crew member #2 to hospital. The elapsed time from the point of the injury, to crew member #2 assessments and treatment by the two paramedics to patient transport was approximately 11 minutes. This injury occurred just outside the city limits of Hood River and transportation to the local hospital was less than 6 minutes. Procedures in the Incident Medical Plan were followed. Crew member #2 was admitted to the Hood River County Hospital and later referred to Oregon Health Science University hospital for a more complete evaluation. 7

8 Management Response The CRGNSA FDO conducted an After Action Review (AAR) with all those who were involved in the incident (excluding crew member #2) the afternoon of the incident. During the AAR someone mentioned at the lip of the bench the rope made contact with some moss. It is well known that vegetation along this steep slope is primarily all that holds loose rock to the landscape. The rope contacting the moss could have loosened the rock but this was not unique to the bench area of the fire. Crews on this fire were very mindful of these conditions and briefed specifically to hazards of working in this terrain as witness by the Agency Administrator during a briefing break out. After the injury to crew member #2, the CRGNSA Fire Management Officer and Agency Administrator immediately requested a Facilitated Learning Analysis (FLA). The FLA team was asked to focus on three areas: What happened in the injury event Medical response of the incident Overview and process of the Ropes Program and its usage within fire operations at the CRGNSA Lessons Learned by the FLA Team Overview of Ropes Program within the CRGNSA Fire Program The rope belay program developed by CRGNSA Fire grew out of an effort to address the safety needs of the organization. The history of using ropes to access steep terrain during fire assignments on this unit goes back to The CRGNSA fire leadership was concerned that using fire hose to ascend and descend a fireline and/or fire was putting firefighters at risk. The Fire Management Officer stated, Fire hose was not designed for this application, and I wanted ropes or a system that is designed for this application. The program has evolved to incorporate the USFS Tree Climbing training along with specific low angle rope training, provided by local experts. Having a program dedicated to using ropes in conjunction with certified training curriculum is viewed as essential to mitigating the risk associated with firefighting safely in steep, rocky, and loose terrain by the fire managers of the CRGNSA. 8

9 By using rope systems to belay firefighters working in the steep and loose terrain in the Columbia River Gorge area, the organization has been able to partially mitigate the risk of a serious fall in unforgiving terrain. Belay can be defined as a variety of techniques used in climbing to exert friction on a climbing rope so that a falling climber does not fall very far. Belays are commonly used in rock, snow and ice climbing and in many work environments where a fall would result in serious injury (window washing, utility work, arbor work, etc.). A belay may be accomplished by one Low angle rappel above Hwy 30 person in a stable position belaying a climber or by self-belay, where a climber manages their own belay (e.g. Rappelling). In either case, the minimum equipment required includes: waist or body harness rope belay device The rope must be affixed to a stable anchor (e.g. a tree, large rock or parked vehicle). FLA Lessons Learned While adding rope belay to the CRGNSA fire program has increased personnel safety overall, doing so has increased the complexity of fighting fire when such techniques are employed. In doing so, some risk has been added. This added complexity increases risk. Mitigating this risk demands additional attention to: Equipment Training Standards Management Support During the development of the rope belay program all of these items have been addressed to some extent, but the most beneficial Lessons Learned from the incident, is that the CRGNSA could benefit from a deeper examination of each of these areas. 9

10 Equipment The rope belay program equipment currently used by CRGNSA Fire is adequate and has been well maintained. There are upgrades, however, that may allow for an even larger safety margin: Equipment use and inventory logs. Implementing the use of heat-resistant ropes. Belay devices that allow for greater control of descent and ascent and provide automatic stopping in the event of loss of user input/control (e.g. Grigri). Training Earlier this year, CRGNSA Fire incorporated the USFS Tree Climbing training as one facet of its ropes training. Only those who successfully complete this multi-day course are permitted to employ rope belay. Attending the course and participation in the program is voluntary. It is exemplary that this unit has taken it upon themselves to self-regulate the requirements for personnel to be involved in the program. Even before this implementation, other rope training was regularly provided by knowledgeable individuals to those in the program. Assessing the applicability of the USFS Tree Climbing training to the fire environment Rope Belay Program should, however, be more fully evaluated. While there is no doubt that the Tree Climbing training offers a great deal of crossover, the Rope Belay Program employs the use of climbing rope in a markedly different environment with hazards that are not fully addressed in the Tree Climbing course of curriculum. Building anchors, lateral movement in terrain & swinging hazards, working side-by-side with partners, and use of rope in a fire environment are just a few examples of topics that might be addressed in training specific to CRGNSA Rope Belay Program. High quality rope training programs are offered by the private sector, and these organizations would likely work to customize their trainings to adapt to the needs of the Rope Belay Program. Exposure to state-of-the -art climbing/rope techniques and equipment would be beneficial to this program. 10

11 Training standards already recommended from members within the program: Replace standard climbing ropes with heat resistant ropes Establish training standards in writing and include regular refresher sessions Identify additional instructors so the program is not dependent on one person. Resurrect rope logs that haven t beencompleted since the last time the ropes were replaced, even though rope logs reportedly aren t a requirement for non-rescue work. Update training for spotters to ensure they speak up if a better option for coming down is evident. Standards Perhaps the greatest Lessons Learned that can be taken from this event is the need for a written operating plan, SOP s, safety checklist and/or risk analyses. This would not only standardize the practices of the program, but it would provide a common understanding of the scope of practice of the program. Exactly what is necessary is a discussion that should begin now within the organization. A job hazard analysis developed by CRGNSA Fire for firefighting while on rope belay already exists and was last updated in 2010 and was reviewed and signed in The JHA was the risk analysis tool used to evaluate the hazards of accessing steep ground by the firefighters. Beyond this there is little to provide documentation of the program. A more detailed operating plan describing when and how rope belay will be used was slated for development, but as yet does not exist. Things to consider in the written operating plan would, at a minimum include: Anchoring from the above bench Scope of use Standard Operation Procedures Updated JHA for rope use on fires Operational Risk Management Analysis and Go-No-Go checklist Operation Approval protocol 11

12 Depending on the level of risk identified by the team and duty officer during the risk analysis process of each particular mission, approval for the operation might be bumped up to a higher management level (FEO -> FMO -> Agency Administrator) It is understood that use of climbing aids for wildland firefighting in steep terrain is common wherever firefighting occurs. Makeshift techniques include pulling on hose, vegetation or braided rope and other methods to secure a footprint. It may prove helpful to investigate whether any other advanced rope belay programs exist within the nation. Investigation into identifying such programs was beyond the scope of this FLA. Should other programs be found, it may help to review and incorporate their applicable standards or perhaps collaborate. If none are discovered, it might prove useful to share what is developed at the CRGNSA with other interagency fire programs. Because firefighting in steep terrain is not unique to the CRGNSA and a wide variety of techniques are currently being employed by wildland firefighters with little or no review, the FLA team highly recommends that the lessons learned through this event be considered at the national level with an eye toward reviewing the safety of current practices throughout the fire service. Management Support and Approval In order to be fully successful, the CRGNSA Rope Belay Program must be supported, approved and embraced by CRGNSA management. It would be highly beneficial if the region were also involved, supportive, and committed to the program. Home-grown programs can be reticent to share with upper management the full extent of the practices being employed by the program for fear that their non-standard practices will be met with disapproval solely on the basis of their non-standardness. Such reticence is understandable and not unfounded. The CRGNSA fire program should be proud of their efforts to address the safety needs of their organization by employing techniques used in the climbing and other work environments where steep or vertical terrain present a challenge to safety. These practices should be more fully documented and reviewed by local and regional management for approval or disapproval. 12

13 Risk Mitigation When properly employed, a belay rope in steep terrain reduces the overall risk and consequences of a fall. When a belay rope is employed, however, additional risks are added that ought to be factored in when considering whether rope belay is the appropriate tool for the mission. The belay rope may dislodge loose materials/debris from above the person on rope which can be a serious hazard to both the individual on rope and other personnel down below. It is probable that this was the source of the rock fall that injured the firefighter on this incident. It can be tempting to rely solely upon ones belay for safety while on belay. Any failure in equipment, improper rigging or failure to properly mind the belay on the part of the firefighter can result in serious injury or death. Mitigating these risks: Assessment of terrain suitability for rope belay (including steepness, looseness and other rolling hazards) during the decision process of whether to employ rope belay. Reducing or eliminating personnel located in the fall line of those on the rope below belay operations. Thorough scouting of descent routes prior to rope belay operations - with the intent of identifying those routes with minimal, potential loose and hazardous debris. Manage the belay rope at all times to minimize slack that could result in a greater fall. When on belay, climb and down-climb manage the rope but avoid relying on belay rope when possible to reduce the risk of falling due to equipment failure, incorrect rigging or anchor failure. Protocols to ensure equipment is properly rigged and employed including buddy checks Back up safety systems for firefighters on belay can be employed to assure that should a person lose control of their belay, their descent is arrested. Kevin Donham FLA Team Leader Glenn Kessler Subject Matter Expert 13